What is an internal appeal?
An internal appeal (utilization review appeal) asks the health plan or its utilization review agent (URA) to reconsider an adverse determination—when care is denied, reduced, or not authorized.
This is different from independent review, where a TDI-certified independent review organization (IRO) reviews the case after internal review in most situations.
General walkthrough: Appeals roadmap.
Texas appeal timelines
Chapter 4201 (utilization review appeals)
Texas's Chapter 4201 (Subchapters K and related provisions) sets appeal procedures for utilization review agents and regulated health carriers. For many TDI-regulated plans:
- Standard appeal decision: as soon as practicable, not later than 30 calendar days after the URA receives the appeal (§ 4201.359)
- Expedited appeals (emergency care, continued hospitalization, Rx/IV, step therapy exceptions): based on medical immediacy, not more than 1 working day after all information needed to complete the appeal is received (§ 4201.357)
- Appeal notices must explain your right to seek independent review by a TDI-certified IRO (§ 4201.359)
When you can skip internal appeal
Texas law allows immediate IRO review without internal UR appeal when:
- The enrollee has a life-threatening condition (§ 4201.360)
- The denial involves prescription drugs or IV infusions for which you are receiving benefits under the policy (§ 4201.3601)
In those cases, go directly to Texas independent review.
Federal internal appeal standards
Many HealthCare.gov and non-grandfathered group plans also follow federal rules: 180 days to file, 30/60-day decisions, 72-hour urgent appeals—check your denial notice.
How to file
- Read the denial for appeal instructions and deadlines.
- Submit in writing when possible—include member ID, authorization or claim numbers, and clinical support.
- Request expedited review if delay would seriously jeopardize life or health.
- Keep copies of everything sent and the date sent.
Carrier links: Texas prior auth & internal appeals links.
Evidence that helps
- Treating clinician letter on medical necessity
- Insurer's clinical criteria (request in writing if not provided)
- Peer-reviewed literature for experimental/investigational disputes
Medicaid appeals
Texas Medicaid managed care uses MCO appeal procedures, then an HHSC state fair hearing:
- Contact your MCO using instructions on the Notice of Adverse Benefit Determination
- State fair hearing: generally 90 calendar days from the denial notice for direct HHSC actions; 120 calendar daysfrom the MCO's final determination for MCO-related appeals (HHSC fair hearings FAQ)
- Requests may be made by phone, mail, or in person—good-cause extensions possible for late filings
After internal appeal
If you receive a final denial, you may request independent review by submitting TDI Form LHL009 to the company that denied care (see external review guide). Federally regulated plans may also allow four months for federal external review.